1. The paper claim: cms-1500 (08-05)
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.

2. Background & Submission of the CMS-1500
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.

3. Learning Objectives
Discuss the history of the Health Insurance Claim Form (CMS-1500 [08-05]).
Define the two types of claims submission.
Explain the difference between clean, pending, rejected, incomplete, and invalid claims
Abstract from the patient record relevant information for completing the CMS-1500 (08-05) insurance claim form.
Describe basic guidelines for submitting insurance claims.
Describe reasons why claims are rejected.
Explain procedures that will minimize the number of insurance forms returned because of improper completion.
Identify techniques required for optically scanned insurance claims.

4. History of the Claims Process
Standard form created in 1958
AMA approved a “universal claim form” in 1975.
Originally called Health Insurance Claim Form (HCFA-1500)
Now called CMS-1500 (08-05)
Revised form made available for optical scanning in 1990
Revised form for NPI inclusion made available in 2005
Describe the advantages of the CMS-1500 (08-05). (Standard format will expedite claims processing.)
Explain why the changes were made over time. (Claim submission technology changed and new information was required on the claim form, so changes were necessary.)
When the ICD-10-CM is adopted in 2013, claims must be able to accommodate as many as ten to twelve 7-digit diagnostic codes per claim. Because of this, the CMS-1500 will morph into the Uniform Bill (UB-04) claim format and will become the electronic ASC X12 version 5010 to be implemented in The UB-04 is the form used for inpatient hospital claims and is discussed in more detail in Chapter 17. Chapter 8 explains ASC X12 version 5010.

5. Types of Claims Paper claim Electronic claim
Submitted on paper or optically scanned
Typed or computer-generated
Electronic claim
Submitted via electronic method
Digital file not printed on paper
What electronic methods are used to submit an electronic claim? (Modem, direct data entry, DSL, FTP)

6. Claim Status
Clean claim: claim was submitted within the program or policy time limit and contains all necessary information
Physically clean claim: has no staples or highlighted areas, bar code area has not been deformed
Rejected claim: not processed or cannot be processed
Pending claim: held in suspense because of review or other reason
List the four criteria for a clean claim according to Medicare. (No deficiencies and passes all electronic edits, carrier does not need to investigate before paying the claim, claim is investigated on a postpayment basis, claim is subject to medical review with attached information or forwarded simultaneously with EMC records)
Give the general term for Medicare claims that are not considered “clean” and which require investigation or development on a prepayment basis (“other” claims).

7. Claim Status (cont’d.) Incomplete claim: missing required information
Invalid claim: contains complete, necessary information but is illogical or incorrect
Dirty claim: submitted with errors, requiring manual processing for resolution, or rejected for payment
Deleted claim: canceled, deleted, or voided by a Medicare fiscal intermediary
Explain how these claims are handled. (Most claims can be resubmitted with additional information.)
Describe the time limit for processing participating provider electronic submissions (within 14 days of receipt) and for paper submissions (27 days after receipt).

8. Abstracting From Medical Records
To complete insurance claim forms
When sending a letter to justify a health insurance claim after professional services are rendered
When a patient applies for life, mortgage, or health insurance
Discuss legal issues of properly abstracting information from the patient’s medical records. (There may be legal guidelines to follow with patient information, such as disclosing HIV status or previous conditions. HIPAA has requirements for this type of disclosure.)

9. Abstracting Examples
Fig. 7-1A shows a sample chart note showing important information to read through and abstract for insurance claim completion.
Point out the main areas of the note to students.
FIGURE 7-1 A, Example of a chart note illustrating important information to read through and abstract for insurance claim completion.

10. Abstracting Examples (cont’d.)
Fig. 7-1B shows the location of abstracted information on a CMS-1500 insurance claim form in OCR format.
FIGURE 7-1  B, The location of the abstracted information placed in the blocks on a CMS-1500 (08-05) insurance claim form in OCR format.

11. Completion of Insurance Forms
Diagnosis
Service dates
Consecutive dates
No charge
Physician’s identification numbers
Insurance biller’s initials
Proofread
Supporting documentation
Office pending file
A diagnosis should never be submitted without supporting documentation in the medical record.
Dates must be consistently formatted in all blocks on the claim form.
Should a claim be filed if there was no charge for a service? (No.)
Be sure to use the correct identification numbers on the claim form.
Be sure the physician signs and initials claims, where appropriate.
What should be included on all supporting documentation? (Patient’s name, subscriber’s name, date of service, insurance identification number)

12. Common Reasons for Claim Delay or Rejection
Submitted to secondary instead of primary
Missing information
Insurance ID # is incorrect
Subscriber information incorrect
Failure to indicate whether patient’s condition is related to employment or an “other” type of accident
Patient or provider signature is missing
Ask students to list other common reasons. (Answers will vary.)
Discuss how each of these reasons for rejection can be avoided.
See Table 7-1

13. Basic Guidelines for Submitting a Claim
Individual insurance
Group insurance
Secondary insurance
Define the terms listed on the slide. (Individual insurance is a private insurance plan; group insurance is usually through an employer, with the patient being a member of the group; secondary insurance is when two insurance policies exist for the patient.)
Explain how individual, group, and secondary insurance each should be handled.
Describe dual coverage.
Explain how consecutive dates are handled on the form.
How are “no charge” services handled?
Explain what the physicians’ identification numbers are and what they are used for.

14. Do’s and dont’s for Completing the CMS-1500
Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.

15. Optical Scanning Do’s and Don’ts
DO: use black typewriter ink, high carbon content one-time Mylar, or OCR printer ribbons.
DO: use original claim forms printed in red ink; photocopies cannot be scanned
DO: align the typewriter or printer correctly so characters appear in the proper fields
DO: enter all information in upper case letters
DO: use alpha or numeric symbols
DO: enter eight-digit date formats
DO: keep signature within signature block
Explain the benefits of OCR. (More control over data input, improved accuracy, increased efficiency in processing)

16. Optical Scanning Do’s and Don’ts (cont’d.)
DON’T: allow characters to touch lines
DON’T: use non-standard fonts
DON’T: handwrite information on the document
DON’T: strike over errors when correcting or crowd preprinted numbers
DON’T: use highlighter pens or colored ink
DON’T: use symbols (#, -, /), periods(.), ditto marks, parentheses, or commas(,)
DON’T: use N/A or DNA when information is not applicable
Explain why these items are incorrect, and refer students to the previous slide or the textbook for the correct methods.

17. Instructions for completing the cms-1500 claim form

18. Patient information

19. Completing the CMS-1500 Claim Form
The following instructions explain how to complete the paper CMS-1500 claim
Required fields
Required if applicable
Not required
Not all blocks on the CMS form must be completed
Refer to payer-specific guidelines
Medicare
Medicaid
Workers Comp

20. Payer Top right corner Payer name Claim mailing address
May be barcoded

21. 1. Program Block Medicare Medicaid Champus ChampVA Group Health Plan
FECA Blk Lung
Other
Check the appropriate block
Refer to the reverse of the form for instructions
The words in (xxxx) tell you what the subscriber ID requirements
Ie SS#, ID#
Only one box can be checked

22. 1a. Insured’s ID Number
Medicare – Social Security number with alpha suffix (or prefix if Railroad)
Medicaid – recipient ID number
Tricare – sponsor’s social security number
Group Health or Individual – policy ID#

23. 2. Patient’s Name Last name, first name, middle initial
Medicare – must match the name on the Medicare ID card exactly
Should match the patient’s ID card
No punctuation (Smith-Jones), (O’Halley)

24. 4. Insured’s Name
Enter the subscriber or policyholder’s name, if different than the patient
Enter SAME if it is the patient

25. 5. Patient Address Enter the patient’s street address No PO boxes
City, State, Zip + 4
Telephone number

26. 6. Patient Relationship to Insured
Self
Spouse
Child
Other
What are some “others?”

27. 3. Patient’s Date of Birth and Sex
MMDDYY
Male or Female

28. 7. Insured’s Address If different than patient
If same as patient, enter SAME

29. 8. Patient Status Married Single Other Employed Full-time student
Part-time student

30. 9. Other Insured’s Name
Leave blank unless the claim is a secondary claim
Enter the Primary payer name

31. 9a. Other Insured’s Policy or Group Number
Leave blank unless this is a secondary claim
Enter the Primary carrier insured’s ID number

32. 9b. Other Insured’s Date of Birth and Sex
Leave blank unless payer-specific instructions indicate otherwise

33. 9c. Employer’s Name or School Name
Leave blank unless payer-specific guidelines instruct otherwise

34. 9d. Insurance Plan or Program Name
Leave blank unless payer-specific guidelines indicate otherwise

35. 10. Is Patient’s Condition Related to
10a. Employment (Current or Previous)
10b. Auto Accident PLACE (State)
10c. Other Accident
Check YES or NO to indicate whether the patient’s condition is related to employment, an auto accident, or other accident.
If the patient’s condition is the result of an auto accident, enter the two-letter abbreviation of the state in which the person responsible for the accident is insured.

36. 10d. Reserved for Local Use
Leave blank unless you are filing a Medicaid secondary claim
Refer to Section MEDICAID SECONDARY for instruction on completing a TPL claim

37. 11. Insured’s Group Policy or FECA Number
Group Number
Why is it important to have the policy’s group number on the claim?
PRICING AGENTS – price then route to patient’s/payer administrator to adjudicate claim

38. 11a. Insured’s Date of Birth and Sex
If insured is someone other than the patient

39. 11b. Employer’s Name or School Name
Employer Name
School Name required if claim is related to a school-related incident-accident
Sports injury

40. 11c. Is There Another Health Benefit Plan?
Check Yes or No
If yes, return to and complete Items 9a-9d
REQUIRED if current claim is a secondary claim

41. 12. Patient or Authorized Person’s Signature
“I authorize the release of information of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below.”
SIGNATURE ON FILE
Date = Date of Service

42. 13. Insured’s or Authorized Person’s Signature
“I authorize payment of medical benefits to the undersigned physician or supplier for services described below.”
SIGNATURE ON FILE
No date

44. PHYSICIAN OR SUPPLIER INFORMATION

45. 14. Date of Current Illness or Injury
Required if applicable
IF Block 10a, 10b, or 10c is checked YES, completing Block 14 may expedite claim processing
Date of first symptom (Illness)
Date of injury (Accident)
Last Menstrual Period (LMP)
May expedite claim processing by not holding up claim for medical records
Why LMP?
Global maternity period
Claim related to pregnancy or separate from pregnancy

46. 15. Date of Same or Similar Illness
Not required unless by payer-specific instructions

47. 16. Dates Patient Unable to Work in Current Occupation
Not required

48. 17. Name of Ordering/ Referring Provider or Other Source
Referring provider name
Required for all Medicare, Railroad Medicare, and Medicare Advantage claims
The ordering provider is required for
Laboratory
Radiology
Medical and Surgical Supplies
Respiratory DME
Enteral and Parenteral Therapy
Durable Medical Equipment
Drugs (J-Codes)
Temporary K Codes
Orthotics/Prosthetics
Temporary Q Codes
Vision Codes
Ordering providers can be an MD, DO, Optometrist, Physician Assistant, Registered Nurse Practitioner, Dentist, Podiatrist, Psychologist, or Certified Nurse Midwife
Medicare Ordering Providers must be an enrolled/credentialed/certified Medicare provider

49. 17a. ID Number of Ordering/Referring Provider
Not required

50. 17b. NPI Ordering/referring NPI number
Required for all Medicare, Railroad Medicare, and Medicare Advantage claims

51. 18. Hospitalization Dates Related to Current Services
Not required

52. 19. Reserved for Local Use Additional claim notes Modifier -99
Indicates 3 or more modifiers for a service code
North Carolina Medicaid Carolina Access #
Medicare – Medical records attached to electronic claim

53. 20. Outside Lab and Charges
Not required
Check NO

54. 21. Diagnosis Codes At least one – up to four diagnosis codes
Priority order
Numeric indicators link to CPT codes in Block 24E Diagnosis Pointer
Enter at least one ICD-9 code describing the patient’s condition. Up to four diagnosis codes are listed in priority order (primary condition, secondary condition, etc) based on coding.
Include numeric codes, V-Codes and E-Codes
Diagnosis codes are linked to specific CPT codes by their order number (SEE BLOCK 24E)

55. 22. Medicaid Resubmission Code
Corrected Medicaid claims
Medicaid Resubmission Code
Numeric code to indicate
Replacement Claim
Void of Previous Claim
Original Ref No
Original ICN (Internal Control Number)
Medicaid claim number

56. 23. Prior Authorization Number
Authorization number approved for service
May have multiple auth numbers
Date of service range
Type of service provided
CLIA number for in-house labs

57. 24A. Dates of Service From – To MMDDYY One Line per service code
One claim per date of service
NDC Qualifier for Drug Codes
In the pink-shaded area, enter the NDC Qualifier of N4 in the first 2 positions, followed by the 11-digit NDC number

58. 24B. Place of Service
Enter the 2-digit code that describes the place of service (POS)
Most common in physician billing
11 Office
21 Inpatient Hospital
22 Outpatient Hospital
23 Emergency Department
24 Ambulatory Surgery Center

59. POS Codes All payers: List appropriate place of service (POS) code.
FIGURE 7-2 Block 24B Place of Service codes.

60. 24C. EMG – Emergency Indicator
Mark this box with an “X” or “Y” if the service was an emergency service, regardless of where it was provided

61. 24D. Procedures, Services, Supplies
CPT/HCPCS
Up to six lines per claim
More than six requires a second claim
Modifier
Appends to service code
Provides additional information to payer regarding service
Affects payment
Enter the CPT/HCPCS procedure code that identifies the service provided. If the same procedure was provided multiple times on the SAME DATE OF SERVICE, enter the procedure only once. Use the units field to indicate the number of times the service was provided on that date. CHECK WITH PAYER FOR SPECIFIC INSTRUCTIONS
For some claims billed with CPT/HCPCS codes, procedure modifiers must be used to accurately identify the service provided and avoid delay or denial of payment

62. 24E. Diagnosis Pointer
Links the service provided to the diagnosis code(s) listed in Block 21 by enter the number of the appropriate diagnosis
Enter only the reference number from Block 21 (1, 2, 3, or 4), not the diagnosis code itself
May have multiple lines with one or more diagnosis
Have to tell the insurance carrier which diagnosis goes with the service
Examples
Annual Check Up with Flu Shot
99835 V72.31
90658 V04.81
90471 V04.81
Office visit for diabetes, hypertension and flu shot
401.9
V04.81
V04.81

63. 24F. Charges Fee/charge for service reported per Line
Units of service – enter total amount of charge for number of units reported
1 unit = $50
Billed units = 3
Total charge = $150.00
Enter the total charges for each service/procedure for the individual Line
Enter the total charges for number of units billed – THE INSURANCE COMPANY WILL NOT CALCULATE YOUR CHARGE FOR YOU!!

64. 24G. Units Enter the number of units provided
Bill all units of service provided on a given date on one line
Units or Days

65. 24H. EPSDT/Family Planning
Not required
Early and Periodic Screening Diagnosis and Treatment
Family Planning
Use FP modifier for Medicaid Family-Planning recipients

66. 24I. ID Qualifier
Not required

67. 24J. Rendering Provider ID#
Rendering physician’s NPI number is reported in the white area
Shaded area may include the taxonomy code, if required

68. 25. Federal Tax ID Number
Enter the tax ID number and check the box labeled “EIN”
If the provider does not have a tax ID, enter the provider’s social security number and check the box labeled “SSN”

69. 26. Patient Account Number
Enter the number assigned to uniquely identify this claim in the provider’s records
Cross-reference between the payer’s claim and the provider’s claim accounting or tracking systemMay be
Medical Record number
Patient account number
Claim control number
This number will be referenced or linked by the payer to the claim processed

70. 27. Accept Assignment Check YES or NO
What happens if you check NO or don’t check either?

71. 28. Total Charge
Total charge for all services reported on the claim

72. 29. Amount Paid Not required
May be used if current claim is secondary and you are reporting primary payer payment
DO NOT use to report patient payments!!
DO NOT use to report expected copays or deductibles due from the patient!!

73. 30. Balance Due
Subtract the Amount Paid (Block 29) from Total Charge (Block 28) and report the Balance Due

74. 31. Signature and Date
Signature of Physician or Supplier including degree or credentials
“I certify that the statements on the reverse apply to this bill and are made a part thereof”
Printed name of rendering provider
Date claim was completed/printed

75. 32. Service Facility Location Information
Name and address of facility where services were provided
32a. Service Facility NPI#
Facility NPI number
32b. Service Facility ID#
Not required

76. 33. Billing Provider, Name, Address, & Phone
Enter the billing providers name, address, and phone number
Practice name
Not always the same as the rendering provider’s name
33a. Billing provider NPI#
Practice or Group NPI
33b. Other ID
Not required unless indicated by payer-specific guidelines

78. HOMEWORK
Link to interactive claim form:
Evolve, Student Resources, Chapter 7
Student Software Challenge Cases
Using Study……Practice completing the claim form for Cases 1-6
Do NOT do them as an Exam!!